Why 30-Day Readmissions Are High

The nurse coordinators also serve as a bridge to providers in the outpatient setting, Ms. Rago said. During the second year of the program, they began making site visits to skilled nursing facilities and reaching out to primary care physicians, cardiologists, and home health agencies from outside of the hospital.

They created an e-mail group for each patient’s care team that includes physicians, nurses, home care, social work, and pharmacy, depending on the services the patient needed. An email goes out to the team at the time of admission and it provides a way to update everyone virtually in real-time about the care of the patient.

Having a closer relationship with the skilled nursing facilities has been a big help, Ms. Rago said. During one of the site visits, the nurses discovered that one of the facilities didn’t offer a low-salt diet. That helped explain why so many patients from that facility were being readmitted to the hospital and they were able to quickly address it, she said.

What physicians need to keep in mind is that while many of these solutions are common sense, there’s no one-size-fits-all approach to readmissions, said Dr. John Rumsfeld, National Director of Cardiology at the Veterans Health Administration and Chief Science Officer for the American College of Cardiology’s National Cardiovascular Data Registry.

"It’s different in each community, so you can’t be prescriptive," he said.

The American College of Cardiology offers resources for reducing readmissions as part of a joint effort with the Institute for Healthcare Improvement called the Hospital to Home initiative.

Unlike other areas of care, such as getting a faster angioplasty, there aren’t six key steps for physicians to implement, Dr. Rumsfeld said. Instead, Hospital to Home is a place for physicians to share best practices based on their individual experiences. So far, more than 1,100 hospitals around the country have signed up.